Lost on the Floor

As I have grown slightly more confident in my ability to treat folks, you get a curve every now and then. I'm getting to the point where I'm a little more confident with cardiac problems. Things like chest pain. I've finally gotten my head around that kind of crisis and am starting to function better and quicker rather than standing there with a dumbstruck look on my face. So when something new comes along, I get that deer in headlights look and feeling.

Case in point:
Older woman had been admitted to the floor for pneumonia and possible UTI, accompanied by that wonderful AMS. When I saw her first in the evening, things were OK. She was alert and mostly oriented, not too far out of it. But she could not hear. If a bomb went off in her room she would not have heard it. Luckily she read lips. But I digress. Lungs sounded diminished, maybe a little crackly, nothing to be very concerned about. But she looked at me and asked, "Am I going to die tonight?" Taken aback I said to her, "Not tonight, we're going to get you through just fine." Yeah, I had to say it.

Then came midnight rounds. It sounded like she had transplanted an aquarium into her chest. Not good. O2 sats were OK, not great, but OK. Tried to get her to cough, not much luck there as the cough was as weak as a newborn kitten. Call the doc, now. Unfortunately she was a hospitalist patient and the house officers were not covering her, so it took a little bit to get a hold of him. Finally did, gave him the report thing, got an order for Lasix. OK, sounds good to me. Well that did nothing, except maybe make her pee a bit. Lungs still sounded like crap. Call RT, just to get an idea of what they thought. One look and listen said it all...she was literally drowning in her own secretions. Again, not good.

Down the nose goes suction, up comes gobs and gobs of creamy yellow/brown sputum. RT remarked that it kind of smelled like Pseudomonas. Not entirely, but not far off. After you clear someone's airway, they breathe much better. Now instead of wet, we had wheezes. At least she was moving air. Call the doc again. New orders, nebs, suction as needed and drop a Foley. I think I've got it locked for the moment. Wrong. Throws me another curve. Temp spikes to over 39C and BP is dropping Call the MD back. By this time I'm sure he is getting tired of hearing my voice. Blood and urine cultures, labs, culture the sputum, get a work-up going, bolus of saline and bump the rate of the fluids after. Keep an eye on her. So I did.

Finished the bolus about 45 minutes before shift change,the Tylenol I had given earlier had brought the temp down to the 37C range. So at least we were making progress. As I was leaving I went back again to check on her. Lungs sounded better,the nebs had helped, sats were back up and BP was improving, but I could see she was tired. Very tired. I looked over at here and said, "Told ya' we'd make it through the night didn't I?" A wan smile and a nod of the head was all I got.

That night when I came back in I looked on the census for her name. Nothing. A cold chill swept over me. Did she go? Did I miss something last night? The knot churned in my stomach until I got out of report and talked her nurse who I was getting report from anyways. "No, she's OK," she said, " we shipped her to the Unit." A little sigh of relief. I heard they tubed her almost immediately on arrival to the Unit, which didn't surprise me at all...let something else do her breathing, at least for the moment. She was stable for the moment.

Once again, I learned. Not a day goes by where something new doesn't come up, a new crisis, a new system to relearn in the crisis, but that's life right now. It made my bleeding patient last night not such a big deal. Perspective is a funny thing ain't it?